Cervical-First Approach in Thoracoscopic Esophagectomy With Intraoperative Nerve Monitoring for an Esophageal Cancer Patient With Aberrant Right Subclavian Artery

An aberrant right subclavian artery (ARSA) is a rare vascular anomaly accompanied by nonrecurrent inferior laryngeal nerve (NRILN). Here, we described the cervical-first approach in thoracoscopic esophagectomy for an esophageal cancer patient with ARSA using the intraoperative nerve monitoring (IONM) system. First, a left cervical procedure proceeded to expose the left vagus nerve to attach the APS electrode of the IONM system, and the left cervical paraesophageal lymph nodes was dissected separately. Subsequently, the NRILN was identified using the IONM system by tracing the right vagal nerve with intermittent manual stimulation. In the thoracoscopic procedures, the right vagal nerve was traced cranially from the bronchial bifurcation, and the dissection continued through the cervicothoracic border up to NRILN without difficulty. Continuous nerve monitoring can ensure safe left upper mediastinal dissection ensuring the left recurrent laryngeal nerve integrity in the narrow upper mediastinum. The postoperative course was uneventful and, the patient was discharged on postoperative Day 21. In patients with ARSA, the cervical-first method in thoracoscopic esophagectomy with IONM is a safer alternative, and left upper mediastinal dissection by the dorsal approach over the esophagus is useful in the restricted space of the upper mediastinum.